1. Richard J Jackson MD Professor and Chair, Environmental Health Sciences UCLA School of Public Health dickjackson@ucla.edu Trail Leaders are Health Leaders Our shaping of the built environment shapes our health, wealth, and future.

2. The Check Up 40 year old parent of two children -- complains of “low energy”

3. “Problem” List Physical exam unremarkable but 28 pounds overweight BP 155/95 Blood glucose elevated, urine normal Cholesterol 270 Signs of Depression No exercise. …Drives to work 25 miles each way Spends 3 to 4 hours a day sitting in a vehicle

4. Treatment Plan Meeting with Nutritionist Weight loss program Exercise club membership Pedometer: 10,000 steps a day Getting more control of work and life commitments

5. Two Months Later… Day is already too full No Time for exercise No place to Walk

6. –Antihypertensive medication –Oral Hypoglycemic agent –Antidepressant –Cholesterol lowering agent Monthly medication costs: –$385 2 months later our colleague is taking:

7. U.S. Health Care Expenditures as Percent of GDP Projections Keehan et al: Health Affairs March/April 2008 27: 145-155

8. An Aging Population Percentage of U.S. Population over Age 65 Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population Copyright 1996, Watson Wyatt Worldwide. 0 5 10 15 20 25 1930195019701990201020302050 Year Percentage of Population

9. Persons employed in health service sites: United States -- 2005 All employed civilians 141,730,000 All health service sites: 14,052,000 –Hospitals: 5,719,000 –Nursing care facilities: 1,848,000 http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary

10. Of the 4,800,000 new jobs in the US 2000-2005 How many were in Health Care? 1.8 million -- 40% http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary

11. “Even under the most optimistic estimates, of the 30 years of increased life expectancy achieved between the 1890s and 1990s, only 5 years can be attributed to medical care.” Bunker cited in Prescription for a Healthy Nation Farley and Cohn 2004

12. We have rigged the “environment” against us…

14. Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

15. Obesity Trends* Among U.S. Adults BRFSS, 1997 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

16. Obesity Trends* Among U.S. Adults BRFSS, 2004 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

17. Bariatric Procedures: Annual Numbers JAMA 2005: pp1909-1917

18. California Prevalence of Overweight* Children aged 5 to 20 years *> 95th percentile BMI-for-age, CDC Growth Charts, 2000. **Year 2010 target: reduce the proportion of children and adolescents aged 6 to 19 years who are overweight to5%. Year 2010 target** 2003 California Pediatric Nutrition Surveillance (PedNSS) 21.7%

19. Supersizing Jet Fuel Use Mean weight gain of Americans in 1990s: 10 pounds Airline distance flown in 2000 in US: 515 billion passenger-miles Weight transported 1 mile by 1 gallon of fuel: 7.3 tons (passengers or cargo) Jet fuel to transport added weight in 2000: 350 million gallons Cost of extra fuel: $1.1 billion (Oct 2005 prices) CO 2 emissions from extra fuel: 3.8 million tons Data sources: NCHS; US Dept. of Transportation

20. Relationship Between BMI and Risk of Type 2 Diabetes Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122:481. Age-Adjusted Relative Risk Body Mass index (kg/m 2 ) MenWomen <22<2323 - 23.9 24 - 24.9 25 - 26.9 27 - 28.9 29 - 30.9 31 - 32.9 33 - 34.9 35+ 1.0 2.9 1.0 4.3 1.0 5.0 1.5 8.1 2.2 15.8 4.4 27.6 40.3 54.0 93.2 6.7 11.6 21.3 42.1

21. No Data 10% Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 1993-94 Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

22. No Data 10% Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 2001 Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

23. Diabetes Projected Risks: For Babies Born in 2000 Girls: 38% lifetime risk –If diabetic before age 40, Lifespan shortened by 14 years (Quality of life by 19 years) Boys: 33% lifetime risk If diabetic before age 40, Lifespan shortened by 12 years. (Quality of life by 22 years) V Narayan et al: JAMA 8 Oct 2003

24. Life Expectancy Is Declining in Some Pockets of the Country NICHOLAS BAKALAR -- New York Times

25. Too Many Calories?

26. “Supersizing” a fast-food meal – the real costs Paying 67 cents to supersize an order — 73% more calories for 17% more money — adds an average of 36 grams of adipose tissue. The future medical costs for that “bargain” would be $6.64 for an obese man and $3.46 for an obese woman. University of WisconsinUniversity of Wisconsin-Madison, Rachel N. Close and Dale A. Schoeller

27. Percentage of Trips in Urban Areas Made by Walking and Bicycling: North America and Europe 1995 Pucher J and Dijkstra L. Promoting Safe Walking and Cycling to Improve Public Health: Lessons From The Netherlands and Germany. AJPH, September 2003;93(9):1509-16.

28. Hu et al. NEJM, December 23, 2004; 351(26):2694-2703. Nurse Study 1976-2000

29. How does this have to do with how we build?

30. The United States has paved over 60,000 square miles of its natural landscape.

31. Less Density = More Driving

32. Miles per capita– more than doubled in one generation Miles per Capita: 1960 to 1995 From 4000 to 9200 VMT per person

33. For every age group from 3 through 33-- crashes were the No. 1 cause of death

34. More time in a car  Higher probability of obesity

35. More walking: Less obesity

36. Higher density and connectivity: Lower obesity– Atlanta study 2004

37. Schools Since World War II –Number of Schools declined 70% –Average School Size grew fivefold, from 127 to 653 students

38. Percent of children who walk or bike to school: 1974  66% 2000  13% (CDC, 2000) We have changed how much we walk or bike

39. Fitness of California’s Children Annual California Fitnessgram Conducted in Grades 5, 7, and 9 Measures 6 major fitness areas (e.g. aerobic capacity, body composition, flexibility) 2004 Results: Who passed all standards? Grade 5  25% Grade 7  29% Grade 9  26%

41. Mindfulness about Food Mindfulness about what and how we eat

42. “…students have better attendance, are less likely to drop out, exhibit fewer discipline problems, and perform better when attending a smaller high school.” Secretary of Education Richard Riley Oct 4, 2000

43. Educational Benefits of Walking and Biking to School Increases concentration Improves mood and ability to be alert Improves memory and learning Enhances creativity

44. Fairfax, California After Starting Program for Safe Routes to School Manor SchoolDrive Alone Walk/Bike/Other Before62%39% After 38%61%

45. Children’s Contact with Nature School age children with ADHD who had higher contact with nature showed better concentration, task completion, and following of directions. Coping with ADD: The Surprising Connection to Green Play Settings” Environment and Behavior, 33 (1), 54-77 AF Taylor, FE Kuo, WC Sullivan, 2001

46. Outdoor Physical Activity Studies in older children show that improved mood and emotional well-being are associated with physical activity. Mood may be affected not only by the physical activity itself but also by exposure to sunlight if the activity occurs outdoors Steptoe A, Butler N. Sports participation and emotional wellbeing in adolescents. Lancet. 1996;347:1789-1792. Wirz-Justice A, Graw P, Krauchi K, et al. “Natural” light treatment of seasonal affective disorder. J Affect Disord. 1996;37:109-120.

47. NYC Mayor Bloomberg Announces PlaNYC to place a park or playground within a ten minute walk for every New Yorker. August 2007 Trust for Public Land

48. 10% increase in urban parks = 4°C decrease in urban surface temperature

51. School Gardens Exercise, Learning, Cooperation, Fun, and It Tastes good

53. “Farmer in Chief” Michael Pollan New York Times October 12, 2008

54. Reversing “The Disease” of the 21 st Century… Depression

55. Income and Happiness SOURCE: Layard, R. Happiness and Public Policy. The Economic Journal 116 (March): C24-C33. Page C25.

56. What does make people happy?

57. Human Contact Being with People we love and who love us

58. Exercise in Healthy Places Treatment for Depression— Exercise Sunlight Nature Contact The health need for places to walk

59. Health – Planning Collaborations SF Bay Area (11 counties) meeting Dec 2006 Los Angeles County (300 attendees) April 2007 Marin, Napa, Sonoma, Solano, El Dorado, San Mateo, Sacramento, San Francisco, Placer, Yolo, Santa Barbara, San Diego, Riverside, Monterey, Humboldt

62. AB 1358 -Complete Streets Act

67. The New Bicycle Commuter 30 minute bicycle trip burns 250 calories each way (for a 190 pound man) 3 days per week = 1500 calories per week, 78,000 calories/year. Converts to 22 pounds of body fat.

68. The New Bicycle Commuter One year follow up Weight - 168 pounds (BMI 24.5) BP - 130/78 Blood sugar – Normal Cholesterol – 175 Energy level and Mood - Good